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A survey of liaison psychiatry services in general hospitals and accident and emergency departments: do we have the balance right?

Published online by Cambridge University Press:  02 January 2018

Tamsin Kewley
Affiliation:
Department of Liaison Psychiatry, St Helier Hospital, Wrythe Lane, Carshalton, Surrey SM5 1AA, e-mail: jim.Bolton@swlstg-tr.nhs.uk
Jim Bolton
Affiliation:
Department of Liaison Psychiatry, St Helier Hospital, Wrythe Lane, Carshalton, Surrey SM5 1AA, e-mail: jim.Bolton@swlstg-tr.nhs.uk
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Abstract

Aims and Method

By use of a telephone survey, we aimed to investigate liaison psychiatry services of all 29 general hospitals in Greater London. We specifically enquired about services to accident and emergency (A&E) departments.

Results

We identified wide variations in staffing, working hours and patient groups seen. Fourteen services (48%) worked over 24 h and 4 (14%) had specific A&E teams. Twelve services (41%) had established or planned working links with community crisis services.

Clinical Implications

Generally staff numbers fell below national recommendations and there were frequent gaps in service provision. The recent focus on emergency care has lead to an increase in A&E services, but there is a risk that liaison psychiatry services for other general hospital patients are being neglected.

Type
Original papers
Creative Commons
Creative Common License - CCCreative Common License - BY
This is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
Copyright
Copyright © Royal College of Psychiatrists, 2006

Although the number of liaison psychiatry services in the UK is increasing, their development is idiosyncratic and services often fail to meet the recommendations of the Royal Colleges of Physicians & Psychiatrists (2003). Across the UK there is a wide variation in staffing and service delivery (Reference Howe, Hendry and PotokarHowe et al, 2003; Reference Ruddy and HouseRuddy & House, 2003; Reference Swift and GuthrieSwift & Guthrie, 2003).

Recent English health service initiatives have led to an increased focus on emergency mental healthcare, which potentially influences liaison psychiatry provision to accident and emergency (A&E) departments. The Department of Health (2001) has recently set standards to reduce patients’ attendance times in A&E departments. In addition, the National Service Framework for Mental Health (Department of Health, 1999) has required specific services to be established for patients in crisis, many of who will attend A&E departments. However, there is no optimum model of psychiatric service delivery to A&E. Also, there is a risk that A&E mental health services develop at the expense of other hospital departments.

As a city, London is unique in the UK in terms of its size, ethnic diversity and organisation of health services. As part of the establishment of a network of liaison psychiatry services in Greater London, we surveyed the current service provision to all the district general hospitals. We aimed to investigate the staffing and service provision of each service and to enquire about service developments, particularly with regard to A&E departments.

Method

Greater London comprises the 32 London boroughs and the City of London. Using information supplied by the Department of Health, 29 Greater London district general hospitals with A&E departments were identified. Information on bed numbers was obtained from hospital websites or directly from bed managers.

During the second quarter of 2004, a telephone survey was carried out using a predetermined list of questions. In each case, we tried to speak to a well-established member of the liaison psychiatry team. We enquired about the number of clinical team members and their professions. Specialist registrars (SpRs) in psychiatry were not included in these figures, as such posts are supernumerary and may not continue beyond the current trainee’s attachment. We established details of service delivery. Hours of work were categorised into services operating within core ‘working hours’ (09.00 to 17.00 h, Monday to Friday), those delivering an extended-hours service and those running 24 h per day. The survey enquired about specific patient groups seen and whether teams were funded and managed by a mental health or an acute trust. We also enquired whether the hospital had a mental health in-patient unit on site. Efforts were made to establish whether there were trends in service development by asking about recent service changes and teams’ priorities for future development.

Data were analysed using the Statistical Package for the Social Sciences version 11.5 for Windows. Staffing levels were compared with the joint Royal College recommendations (Royal Colleges of Physicians & Psychiatrists, 2003).

Results

Information was obtained from all 29 district general hospitals. Four hospitals had separate liaison psychiatry teams covering either A&E or the rest of the hospital. In such instances, data from these two teams were combined in order to compare services between hospitals. Table 1 gives a profile of the different services and Table 2 summarises their staffing levels.

Table 1. Profile of 29 liaison psychiatry services in London

Liaison psychiatry services, n (%)
Separate A&E and in-patient services Hours of service 4 (14)
     Working hours (09.00 to 17.00 h) 5 (17)
     Extended hours 10 (35)
     24 h 14 (48)
Patient groups seen
     A&E 29 (100)
     In-patients 24 (83)
     Out-patients 18 (62)
     Children and adolescents 3 (10)
     Older adults 19 (66)
     Alcohol and substance misuse 23 (80)
     Self-harm 29 (100)

Table 2. Staffing of 29 liaison psychiatry services in London1

Number of staff, mean (s.d.)
Hours of service Medical Nursing Other Total
Working hours (n=5) 1.8 (1.0) 2.5 (1.6) 0.3 (0.7) 4.2 (2.6)
Extended hours (n=10) 1.4 (1.4) 3.5 (1.7) 1.1 (2.1) 6.0 (5.0)
24 h (n=14) 1.7 (2.0) 8.8 (4.9) 0.8 (1.3) 11.3 (5.9)

Bed numbers

The mean number of in-patient beds for the hospitals surveyed was 635 (range 257–1267, s.d.=228).

Working hours

Of the ten services working extended hours, seven included weekends and three operated on weekdays only.

Staffing

Overall, the size of teams varied between 1 and 25 whole-time equivalent staff (mean=8.2, s.d.=5.9). Nine teams (31%) consisted of nursing staff only. Ten services (34%) had no dedicated consultant psychiatry sessions, although these teams usually mentioned that they could contact a psychiatrist for advice.

Patient groups

All teams provided a service to their A&E department and assessed patients following episodes of self-harm. Five services (17%) operated in A&E departments only. Patient groups seen are listed in Table 1.

Services for older adults

Nineteen services (66%) accepted referrals of older adults, although 3 of these teams worked only in the A&E department. Several teams mentioned that community psychiatry services for older adults visited the hospital to see patients. Four on-site liaison psychiatry services specifically for older adults were identified, for which limited data were collected. Each had a half-time consultant with one to two additional nursing or junior medical staff.

Funding and management

Twenty-five services (86%) were managed by the mental health trust, 3 (10%) by the acute trust and 1 (3%) was jointly managed. Fifteen services (52%) were funded by the mental health trust, 10 (35%) were jointly funded and 4 (14%) were funded by the acute trust.

On-site psychiatric unit

Eighteen district general hospitals (62%) also had a psychiatric unit on site. There was a significant association between the presence of an on-site unit and the liaison psychiatry team delivering a 24-h service (χ2=6.43, P=0.01).

Service developments

Those teams providing extended and 24-h services generally reported that they had increased their hours of service during the previous 2 years. Three teams (10%) reported that they also delivered the local mental health crisis or home treatment service. A further 9 services (31%) reported plans to establish closer links between liaison psychiatry and community crisis services.

The most frequently cited priority for service development was for more staff, mentioned by 24 services (83%). However, only 8 teams (28%) had plans to expand. The second most common priority was for more accommodation, which was mentioned by 10 services (35%).

College recommendations

The joint recommendations of the Royal Colleges of Physicians & Psychiatrists (2003) for a liaison psychiatry service are based on a 09.00 to 17.00 h service in an average-sized district general hospital. Such a service should include one full-time consultant, a senior house officer, 5 nursing staff and 1–2 psychologists.

It is difficult to compare the recommendations with services delivering extended-hours and crisis services. However, only 13 teams (45%) had a full-time equivalent consultant and 17 (59%) had a full-time junior doctor. Only 14 services (48%) had 5 or more full-time equivalent nursing staff; 13 of these delivered a 24-h service and 1 an extended-hours service. Only 1 team had more than 1 full-time equivalent psychologist. Overall, only 1 extended-hours service had all of the recommended components.

Discussion

This is the first survey to investigate liaison psychiatry provision to London’s district general hospitals. It identifies wide variations in staffing, hours of work and patient groups seen. All except one service fell short of the recommendations for service provision. However, there has been a recent expansion in services to A&E departments.

Many teams reported that changes in service provision to A&E departments had occurred as a result of recent government targets. A minority of teams also delivered community crisis and home treatment services, work that falls outside the generally accepted remit of a liaison psychiatry service and complicates the interpretation of the survey data.

The recent government targets for emergency mental health provision can be considered an opportunity to bring mental health resources into the district general hospitals. However, there is also a danger that the development of A&E services will be at the expense of services for other general hospital patients.

There is no recommended model for psychiatry service provision to A&E departments. Further qualitative research might help to establish recommendations for A&E services and how emergency mental health services in general should be delivered.

The London population has a number of characteristics that, although not unique among urban areas in the UK, contribute to relatively high levels of mental illness and an associated need for services (Mayor of London, 2003). These include large refugee and minority ethnic populations, high levels of homelessness and single occupancy households, and the fact that London contains many of the most deprived areas in the UK.

Compared with data from previous regional surveys in the UK (Reference Howe, Hendry and PotokarHowe et al, 2003; Reference Ruddy and HouseRuddy & House, 2003), a higher proportion of London district general hospitals had some form of liaison psychiatry service and a higher proportion of services had dedicated consultant psychiatry sessions. However, the combined picture is one of unmet need and a lack of rational planning of services.

Limitations

This study is likely to underestimate the provision of mental health services for general hospital patients, as a number of possible psychiatric and psychological services were not surveyed. Community psychiatric services for children, older adults and substance misuse may provide a consultation service to their local hospital. In addition, individual hospital departments may also employ therapists and psychologists to work with individual patient groups.

An underestimate of services may also have been a result of the omission of SpRs from the survey. Although SpRs are supernumerary and posts are not necessarily filled every year, where present SpRs make a significant contribution to service provision.

We compared each service with the recommendations for an average district general hospital. However, the needs for psychological services of individual hospitals will vary depending on bed numbers, the workload of the A&E department and the epidemiology of the local population. The Colleges’ recommendations also point out that larger teaching hospitals with tertiary referral centres will require a larger liaison psychiatry team, including at least two full-time consultant psychiatrists.

Conclusions

This survey describes the wide variety in liaison psychiatry provision to London’s district general hospitals, with services generally falling below the recommended standards. Although the focus on A&E provides an opportunity to increase liaison psychiatry services for one hospital department, there is a risk that the needs of other patient groups will be neglected. When services are planned the whole hospital should be considered to ensure that all patients receive comprehensive care.

Acknowledgements

We thank Brendan McLoughlin and the London Development Centre for Mental Health who supported the study. We also thank all the liaison psychiatry staff who participated in this survey.

References

Department of Health (1999) National Service Framework for Mental Health: Modern Standards and Service Models. London: Department of Health.Google Scholar
Department of Health (2001) Reforming Emergency Care: First Steps of a New Approach. London: Department of Health.Google Scholar
Howe, A., Hendry, J. & Potokar, J. (2003) A survey of liaison psychiatry services in the south-west of England. Psychiatric Bulletin, 27, 9092.Google Scholar
Mayor of London (2003) Availability of Mental Health Services in London. Highlights of a Report to the Mayor of London. London: Greater London Authority. http://www.london.gov.uk/mayor/health/mentalhealth_availability/mentalhealth_highlights.pdf Google Scholar
Royal College of Physicians & Royal College of Psychiatrists (2003) The Psychological Care of Medical Patients: A Practical Guide (Council Report CR108). London: Royal College of Physicians & Royal College of Psychiatrists.Google Scholar
Ruddy, R. & House, A. (2003) A standard liaison psychiatry service structure? A study of the liaison psychiatry services within six strategic health authorities. Psychiatric Bulletin, 27, 457460.Google Scholar
Swift, G. & Guthrie, E. (2003) Liaison psychiatry continues to expand: developing services in the British Isles. Psychiatric Bulletin, 27, 339341.Google Scholar
Figure 0

Table 1. Profile of 29 liaison psychiatry services in London

Figure 1

Table 2. Staffing of 29 liaison psychiatry services in London1

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